Pregnancy and

Thyroid Disease
National Endocrine and Metabolic Diseases Information Service

What is thyroid disease? Pituitary

Thyroid disease is a disorder that affects the gland
thyroid gland. Sometimes the body produces
too much or too little thyroid hormone.
U.S. Department
of Health and Thyroid hormones regulate metabolismthe
Human Services way the body uses energyand affect nearly
every organ in the body. Too much thyroid
NATIONAL hormone is called hyperthyroidism and can
INSTITUTES
OF HEALTH cause many of the bodys functions to speed
up. Too little thyroid hormone is called TSH
hypothyroidism and can cause many of the
bodys functions to slow down.
Thyroid hormone plays a critical role dur- Thyroid
ing pregnancy both in the development of a
healthy baby and in maintaining the health of
the mother.
Women with thyroid problems can have a T3-T4
healthy pregnancy and protect their fetuses
health by learning about pregnancys effect
on the thyroid, keeping current on their thy- The thyroids production of thyroid hormonesT3
roid function testing, and taking the required and T4is regulated by TSH, which is made by the
pituitary gland.
medications.
What is the thyroid?
The thyroid is a 2-inch-long, butterfly-shaped
gland weighing less than 1 ounce. Located
in the front of the neck below the larynx, or
voice box, it has two lobes, one on either side
of the windpipe. The thyroid is one of the
glands that make up the endocrine system.
The glands of the endocrine system produce,
store, and release hormones into the blood-
stream. The hormones then travel through
the body and direct the activity of the bodys
cells.
The thyroid gland makes two thyroid hor-
mones, triiodothyronine (T3) and thyroxine
(T4). T3 is the active hormone and is made
from T4. Thyroid hormones affect metabo-
lism, brain development, breathing, heart
and nervous system functions, body tempera-
ture, muscle strength, skin dryness, men-
strual cycles, weight, and cholesterol levels.
Thyroid hormone production is regulated by
thyroid-stimulating hormone (TSH), which
is made by the pituitary gland in the brain.
When thyroid hormone levels in the blood
are low, the pituitary releases more TSH.
When thyroid hormone levels are high,
the pituitary responds by decreasing TSH
production.
2 Pregnancy and Thyroid Disease
How does pregnancy
normally affect thyroid
function?
Two pregnancy-related hormoneshuman
chorionic gonadotropin (hCG) and
estrogencause increased thyroid hormone
levels in the blood. Made by the placenta,
hCG is similar to TSH and mildly stimulates
the thyroid to produce more thyroid hor-
mone. Increased estrogen produces higher
levels of thyroid-binding globulin, also known
as thyroxine-binding globulin, a protein that
transports thyroid hormone in the blood.
These normal hormonal changes can some-
times make thyroid function tests during
pregnancy difficult to interpret.
Thyroid hormone is critical to normal
development of the babys brain and nervous
system. During the first trimester, the fetus
depends on the mothers supply of thyroid
hormone, which comes through the placenta.
At around 12 weeks, the babys thyroid
begins to function on its own.
The thyroid enlarges slightly in healthy
women during pregnancy, but not enough to
be detected by a physical exam. A notice-
ably enlarged thyroid can be a sign of thyroid
disease and should be evaluated. Thyroid
problems can be difficult to diagnose in
pregnancy due to higher levels of thyroid
hormone in the blood, increased thyroid size,
fatigue, and other symptoms common to
both pregnancy and thyroid disorders.
Hyperthyroidism
What causes hyperthyroidism in
pregnancy?
Hyperthyroidism in pregnancy is usu-
ally caused by Graves disease and occurs
in about one of every 500 pregnancies.1
Graves disease is an autoimmune disor-
der. Normally, the immune system pro-
tects people from infection by identifying
and destroying bacteria, viruses, and other
potentially harmful foreign substances. But
in autoimmune diseases, the immune system
attacks the bodys own cells and organs.
With Graves disease, the immune system
makes an antibody called thyroid-stimulating
immunoglobulin (TSI), sometimes called
TSH receptor antibody, which mimics TSH
and causes the thyroid to make too much
thyroid hormone. In some people with
Graves disease, this antibody is also associ-
ated with eye problems such as irritation,
bulging, and puffiness.
Although Graves disease may first appear
during pregnancy, a woman with pre-
existing Graves disease could actually see
an improvement in her symptoms in her
second and third trimesters. Remissiona
1Komal PS, Mestman JH. Graves hyperthyroidism
and pregnancy: a clinical update. Endocrine Practice.
2010;16(1):118129.
3 Pregnancy and Thyroid Disease
disappearance of signs and symptomsof
Graves disease in later pregnancy may result
from the general suppression of the immune
system that occurs during pregnancy. The
disease usually worsens again in the first
few months after delivery. Pregnant women
with Graves disease should be monitored
monthly.2
More information about Graves disease
is provided by the National Endocrine and
Metabolic Diseases Information Service
(NEMDIS) in the fact sheet, Graves Disease,
available at www.endocrine.niddk.nih.gov.
Rarely, hyperthyroidism in pregnancy is
caused by hyperemesis gravidarumsevere
nausea and vomiting that can lead to weight
loss and dehydration. This extreme nausea
and vomiting is believed to be triggered by
high levels of hCG, which can also lead to
temporary hyperthyroidism that goes away
during the second half of pregnancy.
2Ogunyemi DA. Autoimmune thyroid disease and
pregnancy. eMedicine website. www.emedicine.
medscape.com/article/261913-overview. Updated April
23, 2010. Accessed August 11, 2011.
How does hyperthyroidism Hyperthyroidism in a newborn can result in
affect the mother and baby? rapid heart rate, which can lead to heart fail-
ure; early closure of the soft spot in the skull;
Uncontrolled hyperthyroidism during preg- poor weight gain; irritability; and sometimes
nancy can lead to an enlarged thyroid that can press against
congestive heart failure the windpipe and interfere with breathing.
Women with Graves disease and their new-
preeclampsiaa dangerous rise in
borns should be closely monitored by their
blood pressure in late pregnancy
health care team.
thyroid storma sudden, severe wors-
ening of symptoms How is hyperthyroidism in
miscarriage
pregnancy diagnosed?
Health care providers diagnose hyperthy-
premature birth roidism in pregnant women by reviewing
low birth weight symptoms and doing blood tests to measure
TSH, T3, and T4 levels.
If a woman has Graves disease or was
treated for Graves disease in the past with Some symptoms of hyperthyroidism are com-
surgery or radioactive iodine, the TSI anti- mon features in normal pregnancies, includ-
bodies can still be present in the blood, even ing increased heart rate, heat intolerance,
when thyroid levels are normal. The TSI and fatigue.
antibodies she produces may travel across
Other symptoms are more closely associated
the placenta to the babys bloodstream and
with hyperthyroidism: rapid and irregu-
stimulate the fetal thyroid. If the mother is
lar heartbeat, a slight tremor, unexplained
being treated with antithyroid medications,
weight loss or failure to have normal preg-
hyperthyroidism in the baby is less likely
nancy weight gain, and the severe nausea
because these medications also cross the
and vomiting associated with hyperemesis
placenta.
gravidarum.
Women who have had surgery or radioactive
iodine treatment for Graves disease should
inform their health care provider, so the baby
can be monitored for thyroid-related prob-
lems later in the pregnancy.

4 Pregnancy and Thyroid Disease

A blood test involves drawing blood at a
health care providers office or commercial
facility and sending the sample to a lab for
analysis. Diagnostic blood tests may include
TSH test. If a pregnant womans
symptoms suggest hyperthyroidism,
her doctor will probably first perform
the ultrasensitive TSH test. This test
detects even tiny amounts of TSH in the
blood and is the most accurate measure
of thyroid activity available.
Generally, below-normal levels of TSH
indicate hyperthyroidism. However, low
TSH levels may also occur in a normal
pregnancy, especially in the first trimes-
ter, due to the small increase in thyroid
hormones from HCG.
T3 and T4 test. If TSH levels are low,
another blood test is performed to mea-
sure T3 and T4. Elevated levels of free
T4the portion of thyroid hormone not
attached to thyroid-binding protein
confirm the diagnosis.
Rarely, in a woman with hyperthyroid-
ism, free T4 levels can be normal but
T3 levels are high. Because of normal
pregnancy-related changes in thyroid
function, test results must be inter-
preted with caution.
TSI test. If a woman has Graves dis-
ease or has had surgery or radioactive
iodine treatment for the disease, her
doctor may also test her blood for the
presence of TSI antibodies.
More information about testing
for thyroid problems is provided
by the NEMDIS in the fact sheet,
Thyroid Function Tests, available at
www.endocrine.niddk.nih.gov.
5 Pregnancy and Thyroid Disease
How is hyperthyroidism treated
during pregnancy?
During pregnancy, mild hyperthyroidism, in
which TSH is low but free T4 is normal, does
not require treatment. More severe hyper-
thyroidism is treated with antithyroid medi-
cations, which act by interfering with thyroid
hormone production.
Radioactive iodine treatment is not an
option for pregnant women because it can
damage the fetal thyroid gland. Rarely,
surgery to remove all or part of the thyroid
gland is considered for women who cannot
tolerate antithyroid medications.
Antithyroid medications cross the placenta in
small amounts and can decrease fetal thyroid
hormone production, so the lowest possible
dose should be used to avoid hypothyroidism
in the baby.
Antithyroid medications can cause side
effects in some people, including
allergic reactions such as rashes and
itching
a decrease in the number of white blood
cells in the body, which can lower a
persons resistance to infection
liver failure, in rare cases

Stop your antithyroid medication and
call your health care provider right away
if you develop any of the following signs
and symptoms while taking antithyroid
medications:
fatigue
weakness
vague abdominal pain
loss of appetite
a skin rash or itching
easy bruising
yellowing of the skin or whites of
the eyes, called jaundice
persistent sore throat
fever
In the United States, health care provid-
ers prescribe the antithyroid medication
methimazole (Tapazole, Northyx) for most
types of hyperthyroidism.
Experts agree that women in their first
trimester of pregnancy should probably not
take methimazole due to the rare occurrence
of damage to the fetus. Another antithry-
roid medication, propylthiouracil (PTU), is
6 Pregnancy and Thyroid Disease
available for women in this stage of preg-
nancy or for women who are allergic to or
intolerant of methimazole and have no other
treatment options.
Health care providers may prescribe PTU for
the first trimester of pregnancy and switch
to methimazole for the second and third
trimesters.
Some women are able to stop antithyroid
medication therapy in the last 4 to 8 weeks
of pregnancy due to the remission of hyper-
thyroidism that occurs during pregnancy.
However, these women should continue to
be monitored for recurrence of thyroid prob-
lems following delivery.
Studies have shown that mothers taking anti-
thyroid medications may safely breastfeed.
However, they should take only moderate
doses, less than 1020 milligrams daily, of
the antithyroid medication methimazole.
Doses should be divided and taken after
feedings, and the infants should be moni-
tored for side effects.2
Women requiring higher doses of the anti-
thyroid medication to control hyperthyroid-
ism should not breastfeed.
Hypothyroidism
What causes hypothyroidism in
pregnancy?
Hypothyroidism in pregnancy is usually
caused by Hashimotos disease and occurs in
three to five out of every 1,000 pregnancies.2
Hashimotos disease is a form of chronic
inflammation of the thyroid gland.
Like Graves disease, Hashimotos disease
is an autoimmune disorder. In Hashimotos
disease, the immune system attacks the thy-
roid, causing inflammation and interfering
with its ability to produce thyroid hormones.
Hypothyroidism in pregnancy can also result
from existing hypothyroidism that is inad-
equately treated or from prior destruction
or removal of the thyroid as a treatment for
hyperthyroidism.
How does hypothyroidism affect
the mother and baby?
Some of the same problems caused by hyper-
thyroidism can occur with hypothyroidism.
Uncontrolled hypothyroidism during preg-
nancy can lead to
preeclampsia
anemiatoo few red blood cells in the
body, which prevents the body from get-
ting enough oxygen
miscarriage
low birth weight
stillbirth
congestive heart failure, rarely
7 Pregnancy and Thyroid Disease
Because thyroid hormones are crucial to
fetal brain and nervous system development,
uncontrolled hypothyroidismespecially
during the first trimestercan affect the
babys growth and brain development.
How is hypothyroidism in
pregnancy diagnosed?
Like hyperthyroidism, hypothyroidism
is diagnosed through a careful review of
symptoms and measurement of TSH and T4
levels.
Symptoms of hypothyroidism in pregnancy
include extreme fatigue, cold intolerance,
muscle cramps, constipation, and problems
with memory or concentration. High levels
of TSH and low levels of free T4 generally
indicate hypothyroidism. Because of normal
pregnancy-related changes in thyroid func-
tion, test results must be interpreted with
caution.
The TSH test can also identify subclinical
hypothyroidisma mild form of hypothy-
roidism that has no apparent symptoms.
Subclinical hypothyroidism occurs in 2 to
3 percent of pregnancies.2 Test results will
show high levels of TSH and normal free T4.
Experts differ in their opinions as to whether
asymptomatic pregnant women should be
routinely screened for hypothyroidism. But
if subclinical hypothyroidism is discovered
during pregnancy, treatment is recom-
mended to help ensure a healthy pregnancy.
How is hypothyroidism treated
during pregnancy?
Hypothyroidism is treated with synthetic
thyroid hormone called thyroxinea medi-
cation which is identical to the T4 made
by the thyroid. Women with preexisting
hypothyroidism will need to increase their
prepregnancy dose of thyroxine to maintain
normal thyroid function. Thyroid function
should be checked every 6 to 8 weeks during
pregnancy. Synthetic thyroxine is safe and
necessary for the well-being of the fetus if
the mother has hypothyroidism.
Eating, Diet, and Nutrition
During pregnancy, the body requires higher
amounts of some nutrients to support the
health of the mother and growing baby.
Experts recommend pregnant women main-
tain a balanced diet and take a prenatal mul-
tivitamin and mineral supplement containing
iodine to receive most nutrients necessary for
thyroid health. More information about diet
and nutrition during pregnancy is provided
by the National Agricultural Library available
at www.choosemyplate.gov/mypyramidmoms/
index.html.
8 Pregnancy and Thyroid Disease
Dietary Supplements
Because the thyroid uses iodine to make thy-
roid hormone, iodine is an important mineral
for a mother during pregnancy. During preg-
nancy, the baby gets iodine from the moth-
ers diet. Women need more iodine when
they are pregnantabout 250 micrograms a
day. In the United States, about 7 percent of
pregnant women may not get enough iodine
in their diet or through prenatal vitamins.3
Choosing iodized saltsalt supplemented
with iodineover plain salt and prenatal
vitamins containing iodine will ensure this
need is met.
However, people with autoimmune thyroid
disease may be sensitive to harmful side
effects from iodine. Taking iodine drops or
eating foods containing large amounts of
iodinesuch as seaweed, dulse, or kelp
may cause or worsen hyperthyroidism and
hypothyroidism. More information about
iodine is provided by the National Library
of Medicine in the fact sheet, Iodine in diet,
available at www.nlm.nih.gov/medlineplus.
To help ensure coordinated and safe care,
people should discuss their use of dietary
supplements with their health care pro-
vider. Tips for talking with health care
providers are available at the National
Center for Complementary and Alternative
Medicines Time to Talk campaign at
www.nccam.nih.gov.
3Zimmerman MB. Iodine deficiency in pregnancy
and the effects of maternal iodine supplementation on
the offspring: a review. American Journal of Clinical
Nutrition. 2009;89(2):668S672S.
Postpartum Thyroiditis
What is postpartum thyroiditis?
Postpartum thyroiditis is an inflammation of
the thyroid that affects about 4 to 10 percent
of women during the first year after giving
birth.2 Thyroiditis causes stored thyroid
hormone to leak out of the inflamed thyroid
gland and raise hormone levels in the blood.
Postpartum thyroiditis is believed to be
an autoimmune condition and causes
mild hyperthyroidism that usually lasts
1 to 2 months. Many women then develop
hypothyroidism lasting 6 to 12 months before
the thyroid regains normal function. In some
women, the thyroid is too damaged to regain
normal function and their hypothyroidism
is permanent, requiring lifelong treatment
with synthetic thyroid hormone. Postpartum
thyroiditis is likely to recur with future
pregnancies.
Postpartum thyroiditis often goes undiag-
nosed because the symptoms are mistaken
for postpartum bluesthe exhaustion and
moodiness that sometimes follow delivery. If
symptoms of fatigue and lethargy do not go
away within a few months or a woman devel-
ops postpartum depression, she should talk
with her health care provider. If the hypo-
thyroid symptoms are bothersome, thyroid
medication can be given.
9 Pregnancy and Thyroid Disease
Points to Remember
Thyroid disease is a disorder that
results when the thyroid gland pro-
duces more or less thyroid hormone
than the body needs.
Pregnancy causes normal changes in
thyroid function but can also lead to
thyroid disease.
Uncontrolled hyperthyroidism dur-
ing pregnancy can lead to serious
health problems in the mother and
the unborn baby.
During pregnancy, mild hyperthy-
roidism does not require treatment.
More severe hyperthyroidism is
treated with antithyroid medica-
tions, which act by interfering with
thyroid hormone production.
Uncontrolled hypothyroidism dur-
ing pregnancy can lead to serious
health problems in the mother and
can affect the unborn babys growth
and brain development.
Hypothyroidism during pregnancy
is treated with synthetic thyroid
hormone, thyroxine (T4).
Postpartum thyroiditis
inflammation of the thyroid
glandcauses a brief period of
hyperthyroidism, often followed by
hypothyroidism that usually goes
away within a year. Sometimes the
hypothyroidism is permanent.
Hope through Research For More Information
The National Institute of Diabetes and American Association of Clinical
Digestive and Kidney Diseases (NIDDK) Endocrinologists
conducts and supports research into many 245 Riverside Avenue, Suite 200
kinds of disorders, including thyroid disease. Jacksonville, FL 32202
Researchers are investigating the develop- Phone: 9043537878
ment, signs and symptoms, and genetics of Fax: 9043538185
thyroid function disorders to further under- Internet: www.aace.com
stand thyroid diseases. Scientists continue to
American Thyroid Association
study treatment options for pregnant women
6066 Leesburg Pike, Suite 550
with thyroid disorders, as well as long-term
Falls Church, VA 22041
outcomes for mothers and their children.
Phone: 1800THYROID (18008497643)
Participants in clinical trials can play a more or 7039988890
active role in their own health care, gain Fax: 7039988893
access to new research treatments before Email: thyroid@thyroid.org
they are widely available, and help others Internet: www.thyroid.org
by contributing to medical research. For
The Endocrine Society
information about current studies, visit
8401 Connecticut Avenue, Suite 900
www.ClinicalTrials.gov.
Chevy Chase, MD 20815
Phone: 18883636274 or 3019410200
Fax: 3019410259
Email: societyservices@endo-society.org
Internet: www.endo-society.org
Graves Disease Foundation
P.O. Box 2793
Rancho Santa Fe, CA 92067
Phone: 18776433123
Fax: 8587565302
Email: gravesdiseasefd@gmail.com
Internet: www.ngdf.org
The Hormone Foundation
8401 Connecticut Avenue, Suite 900
Chevy Chase, MD 208155817
Phone: 1800HORMONE
(18004676663)
Fax: 3019410259
Email: hormone@endo-society.org
Internet: www.hormone.org

10 Pregnancy and Thyroid Disease

Acknowledgments
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was originally reviewed by Lewis Braverman,
M.D., Boston Medical Center, and Linda
Barbour, M.D., M.S.P.H., University of
Colorado Denver. Dr. Braverman reviewed
the updated version of the publication.
11 Pregnancy and Thyroid Disease
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U.S. DEPARTMENT OF HEALTH

AND HUMAN SERVICES
National Institutes of Health

NIH Publication No. 126234

April 2012

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